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Adult Vasectomy Registration – Preview Page
Adult Vasectomy Registration - 2020
In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Clinic Queensland is treated as confidential. To protect your privacy Gentle Procedures Clinic Queensland operates in accordance with this act. (Please tick the items listed to indicate your consent to disclose the following items).
COVID-19 Questionnaire (Patient to complete)
Have you had a fever or temperature in the past 14 days
Have you had a cough in the past 14 days
Have you been unwell with flu like symptoms in the past 14 days
Has anyone in your immediate family travelled oversees in the past 14 days.
Date of birth
Medicare Card Number
Your medicare number should be 10 digits long
Medicare Reference Number
* number to the left of your name
Medicare Expiration Date mm/yyyy
Department of Veteran Affairs
DVA Card Number
DVA Card Expiry Date
DVA Card Colour
Healthcare Card Number (if applicable)
Healthcare Card Expiry Date
Pensioner Card Number (if applicable)
Pensioner Card Expiry Date
Pensioner Card Type
Australian Capital Territory
New South Wales
Preferred Phone Number
Please note this number will be used for all communication including confirming your appointment via SMS.
Add your preferred email
Emergency Contact Name
Emergency Contact Phone
How did you hear about us?
Online Search / Google
GP / Doctor's Referral
Friend or Family Member
General Doctor Details
State / Province / Region
ZIP / Postal Code
Practice Phone (include area code)
Current Relationship Status
What is your current relationship status?
Length of relationship:
Enter “none” if none.
Do you have children together?
Do you have children from a previous relationship?
Is your partner currently pregnant?
Current Method/s of Birth Control: (Tick Appropriate)
Birth control pill
Other (please specify below)
If "other" please specify method:
Medical History: (Tick Appropriate)
Do you suffer or have you suffered with any of these medical conditions.
Ache, pressure or pain in the testicle or groin
Hepatitis A, B, C
Blood clotting disorder
Scrotal or testicular injury or trauma
Other (please specify)
If "other" please specify:
Sexual Health Screening
Due to the nature of the medical procedure you are about to undergo it is vital we know your sexual health history. Have you been diagnosed with:
Sexual Health Screening
Human Immunodeficiency Virus (HIV)
Human Papillomavirus (HPV)
Treating Doctor Details
Please advise of the Doctor Name and contact telephone number
Have you had any of the following operations?
Scrotal or testicular surgery
If Yes, Year performed:
Medications, Are You Taking Any of the Following
Please list any other medications
Known Allergies (Please List)
Please list your allergies
Enter “none” if none.
Please note it is our responsibility to ensure you are aware that there are risks with any medical procedure, including a Vasectomy. You must understand the risks before the procedure is performed. If there is anything you do not understand please leave unticked and this will be discussed at your appointment. (The number in brackets is the risk level for that complication)
I have read all the information in the Gentle Procedures Vasectomy Manual.
I understand that my vasectomy is not fully covered by Medicare.
I know I must not drink alcohol for 48 hours before and after the procedure
I know I must not take Aspirin or any other products containing Aspirin for 7 days before the procedure and for 2 days after the procedure.
I know I must NOT take NSAIDs such as Nurofen, Ibuprofenfor 7 days before the procedure and 2 days after the procedure.
I understand although the use of effective local anaesthetic and additionally for some patients sedation and Penthrox, I cannot be guaranteed a painless procedure & some patients do experience break through pain.
I request that a Vasectomy be performed on my person. I make this request of my own free will, without having been forced or given any special influence.
I understand there are are temporary contraceptive methods available to my partner and I.
I understand the procedure to be performed on me is a surgical procedure, the details of which have been explained to me.
I understand the surgical procedure involves risks, in addition to benefits, all of which has been explained to my satisfaction.
I understand that if the procedure is successful I will be unable to have any more children; however the procedure does not protect me or my partner from infection or sexually transmitted diseases including HIV and AIDS.
I understand the effect of the procedure should be considered permanent (I.e it may NOT be possible to reverse your Vasectomy with subsequent surgery)
I understand I can decided against the procedure at any time before the operation is performed (without losing the right to medical health, or other services or benefits)
I agree to have one semen analysis test done after my Vasectomy to ensure the procedure was successful. Without this I will not know if my procedure was successful.
I understand that there is no fool proof contraception method of any kind that exists today. I understand that even after 2 sperm tests showing no moving sperm present, I can still cause a pregnancy months or years later, however this is highly unlikely (one in many thousands).
In the unlikely event that the patient needed to attend a hospital they may be at risk of catching COVID 19 in a hospital settling and there may not be adequate staff available to attend to them if the pandemic progresses.
Vasectomy Consent Questions
If you have any questions or concerns with the above consent section please list your questions here and it will be discussed in your consultation.
Risks and Possible Complications May Include
Please note it is our responsibility to ensure you are aware that there are risks and potential complications with any medical procedure, including a Vasectomy. You must understand the risks before the procedure is performed. If there is anything you do not understand please add to the questions section.
A bruised sensation to the scrotum for a few days to a week after the procedure.
Some mild bleeding into the scrotum (1/100) which may for a small tender swelling for a few days.
Sperm granuloma– a painful lump that may develop at the site where the tube was blocked made of leaked sperm (1/500), same treatment as above usually effective.
Late failure– a rare outcome in about 1/3000 men who even after successful vasectomy with 2 sperm checks showing no sperm seen, still manage to impregnate their partner.
Epididymitis– tender swelling of the epididymis which is the part of the tube that joins to the testicles (1/50) It almost invariably resolves with anti-inflammatories, ice and rest.
Infection which may require antibiotics (1/100). More serious infection is possible I.e abscess formation that may require intravenous antibiotics.
Scrotal hematoma (1/2000) a major bleed into the scrotum causing a grapefruit size tender scrotum disabling you for 2 months. (You should contact Dr Hunt immediately if you notice any significant swelling in your scrotum after your procedure).
Post Vasectomy pain syndrome (1/1000) – a very rare complication of pain the in the testicles that can persist for months or years and may be quite debilitating. Some men may never completely recover from this problem or it may resolve on its own or another surgical procedure may be required.
Other complications have been reported (1/10,000) Some studies have reported a small increase in prostate cancer after vasectomy. Many other studies have shown no increased risks. Most experts agree that vasectomy does not cause cancer.
Vasectomy Complication Questions
If you have any questions or concerns with the above complication section please list your questions here and it will be discussed in your consultation.
Although effective local anaesthetic and additionally for some patients sedation and Penthrox, I cannot be guarantee a painless procedure and I may experience break through pain.
Yes, I understand I may experience break through pain.
Consent / Privacy / Release of Information
Please note it is our responsibility to ensure you are aware that there are risks with any medical procedure, including a Vasectomy. You must understand the risks before the procedure is performed. If there is anything you do not understand please add to the questions section.
In accordance with the Privacy Act (1988), all information collected by Gentle Procedures Brisbane is treated as confidential. To protect your privacy Gentle Procedures Brisbane operates in accordance with this act. We may use your information provided for any of the following:
Disclosure to others involved in your healthcare including referrals to other health practitioners.
if you answer No we are unable to send a letter to your GP or provide things to you such as a medical certificate.
Sending SMS reminders for appointments using the number provided.
If you answer NO to this you will not receive any appointment reminders.
Leaving voicemails identifying the caller using the phone number provided.
If you answer NO to this means Dr Hunt cannot attempt to contact you post operatively.
Sending communication via email using the email address provided.
If you answer NO to this that means we cannot email you a receipt or aftercare instructions.
Please use your mouse or finger to digitally sign and consent to all items in this questionnaire. Please ensure to sign within the box provided.
The date you have digitally signed this document.
This field is for validation purposes and should be left unchanged.
For Appointments & Enquiries Tel: 07 2103 2322 | Email: email@example.com
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